Presenter; Dr.

Mawala
Facilitator; Dr. Edwin
Outlines
 Introduction
 Definition of some terms
 Vestibular system
 Otolithic organ
 Semicircular canals
 Visual system
 Proprioceptive system
 Summary
 Balance tests
 Clinical correlation
 references
Introduction
 Definitions of some terms;
 Balance is the ability to maintain an upright position.
 Coordination is the capacity to move through a
complex set of movements while maintaining balance.
 vestibular system is the sensory apparatus of the
inner ear that helps the body maintain its postural
equilibrium(balance).
 Balance and coordination depend on the interaction
of multiple systems in the body including the
vestibular (inner ear), visual, touch and
proprioception (referred to feel sense) systems.
 Each of these areas has the ability to sense body
position and motion and they will in turn produce
nerve signals that are sent to the central nervous
system (brain).
 The brainstem and cerebellum, receive and process
the data, which result in a coordinated response that
allows us to maintain our balance and stability in a
number of challenging situations
The vestibular system
 The vestibular system constantly monitors the motion and
position of our head throughout all normal daily activities.
 The vestibular system is housed within the right and left
inner ears.
 The bony labyrinth is filled with a fluid called perilymph
(high concentration of sodium).
 The membranous labyrinth, found suspended inside the
bony labyrinth, contains a fluid called endolymph (high
concentration of potassium).
Vestibular system cont..
 The membranous labyrinth contains the five
individual organs responsible for generating
information about head movement and position.
 These are
 The otolithic organs (utricle and saccule).

 The semicircular canals (anterior, posterior and

horizontal).
The otolithic organs
 The utricle and saccule are two pouch like areas
located in the vestibule.
 The otolithic organs primarily sense linear
movement (forward, backward, sideways) and
tilting of the head.
 The utricle is designed to be most sensitive to
horizontal motion and the saccule is most
sensitive to vertical motion.
 The utricle has connections to the semicircular
canals as well as to the saccule.
The Otolithic
Organs

Saccule: roughly
vertical orientation,
responds to acceleration components within saggital plane

Utricle: horizontal (+ 30 deg.) orientation

 These organs contain groups of highly specific
nerve endings the hair cells, which are arranged
into patches called maculae.
 The hair cells in the maculae are projected up into
a gelatinous bed called the otolithic membrane.
 The top layer of the otolithic membrane is
embedded with calcium carbonate crystals, the
otoconia.
 The otoconia adds a significant amount of weight
to the hair cells of the maculae, causing them to be
highly sensitive to acceleration, deceleration and
gravitational forces.
Detection of linear acceleration
 When we bend down or move forward, the otoconia
embedded on the otolithic membrane will cause a
relative drag, or resistance to motion, due to inertia.
 This action in turn deflects the hair cells that are
attached to the base of the otolithic membrane,
causing them to send impulses along the nerve
pathways to the brain about linear (vertical or
horizontal) or gravitational (tilt or lean) changes.
 Normal upright

 Bend forward
The semicircular canals
 The three semicircular canals; superior, posterior, and
horizontal are positioned at right angles to one
another.
 They are able to detect movements in three
dimensional space
 The semicircular canals contain the groups of hair
cells referred to as cristae.
 The hair cells of each cristae project up into a
gelatinous, diaphragm like structure called the
cupula.
 The cupula completely seal one side of the ampulla
from the other and is designed to detect rotational.
Detection of head rotation
 When the head begins to rotate in any direction, the
inertia of the endolymph causes it to lag behind,
exerting pressure that deflects the cupula in the
opposite direction. This deflection stimulates the hair
cells by bending their stereocilia in the opposite
direction.
 Generating an impulse that is sent along the nerve
pathway to the brain about direction and speed of
head movement.
 Bending of the stereocilia toward the kinocilium
depolarizes the hair cells and increases the rate of
discharge.
 Deflection away from the kinocilium causes
hyperpolarization and decreases the rate of discharge.
 In superior canals these effects are reversed.
 Nerve fibers from the crista and the macula send
movement related information to brain via the
superior and inferior vestibular nerves.
 superior division: utricle, anterior part of saccule,
and horiz & anterior canals
 inferior division: posterior part of saccule, and
posterior canal
 to vestibular nuclei
 to cerebellum
Cranial Nerve VIII
The visual system

 The visual system is a component of balance, there is a

link to the eye muscles, neck muscles and general
body muscles (vestibulo- occular, bulbar, spinal).
 Our visual system allows us to perceive our own
motion and position relative to the world around us.
 Errors in our perception of visual information can lead
to a sensory conflict, resulting in nausea and
dizziness.
 The vestibular-ocular reflex
uses signals from the vestibular
organs to control the position
on the fovea of the retina and
therefore hold images stable
during brief or rapid head
rotations.
The proprioceptive system

 Proprioception refers to the brain’s ability to know

where our body is in space.
 The brain gathers information from a wide range of
senses and then processes this information in order to
compare it with a virtual body map that is stored in
our memory.
Central vestibular connection
 The vestibular nuclei receive afferents from the
vestibular hair cells, cerebellum, reticular
formation, spinal cord, contra lateral vestibular
nuclei and the visual system.
 From the vestibular nuclei neural signals are
relayed to the contra lateral supra sylvian gyrus
just anterior to the auditory cortex
 The cortex interprets this information, making
modifications in eye, head and body position to
maintain a fixed eye position, and erect posture.
Cortex action..
 On realization of a head movement and its
direction;
The cortex relay signals:-
 To the eye muscle nuclei to move the eye ball to
retain the field of last gaze.
 To anterior horn cells to adjust trunk and limb
muscles.
 To cerebellum to adjust muscle tonus.
Summary
 The vestibular system composed of two sensors for
linear and three for angular acceleration.
 The right and left inner ear structures are mirror
images of each other.
 The three elements are important to convert
accelerations of the head to information useful for
the brain, these are inertia, sensory hair cells,
and nerve fibers connected to hair cells.
 Head movement produces compensantory
reflective eye movement. When the head moves
the vestibuloocular reflex stabilizes the image of
an object in space on the retina by producing eye
movement compensatory to the head movement.
Functional
Balance
Navigating in our
Environment
 Compare, Select
& Combine Senses

Visual Vestibular Somato-

System System Sensation

SENSORY INPUTS
Vision
Vestibular
Somatosensory
Balance tests
 PAST POINTING
If a patient with vestibular deficiency is asked
to point at a stationary object, say
examiners finger he will always past Point
towards the affected side.
 CALORIC TESTS:
Under normal circumstances movement of
endolymph in one vestibular apparatus leads
to dizziness and nystagmus. This movement
can be initiated by warming or cooling the
Endolymph.

If there is end organ (vestibular) deficiency the

ocular movement will be poor or absent.
In a caloric test a change of temperature is used to
create a conventional current in endolymph.
 KOBRAK’S TEST
 2cc ice cold water is introduced into the external
auditory canal of a patient who is seated with
head extended. Change of temperature in the
labyrinth causes endolymph movement and
nystagmus that lasts for a certain duration.
 The duration of the nystagmus is proportional to
the functional capacity of the vestibular system.
 FITZGERALD AND HALLPIKE’S TEST
In a recumbent patient with head at 30 degree
to the horizontal the ear is irrigated with water
at 30 degree Celsius and then at 44 degrees
Celsius each for 40 sec.
The duration of nystagmus is timed by a stop watch.
Where no response is noted irrigate the ear with
water at 20 degrees Celsius for 4 minutes. No
responses means a dead ear (dead labyrinth).
ROTATION TEST
Patient is seated upright on a barany chair,
head titled 30 degrees and eyes closed. The chair is
rotated ten times in twenty seconds.The Chair is then
stopped abruptly and patient told to look at examiner’s
finger. The nystagmus is recorded. Under normal
conditions the duration of the nystagmus should be
25-40 seconds. Vestibular defect will shorten duration
of the nystagmus.
ELECTRONYSTAGMOGRAPHY
The eye ball acts like an electrical dipole, with
the cornea having a positive charge and retina
a negative charge. Hence an electromagnetic
field exist around the eye.
Ocular movements will then cause changes in the
electromagnetic field around the eye and an electric
current can be produced and measured by
electrodes
Electronystagmoghraphy CT.
An electronystagmography machine takes advantage of
the above to measure accurately, eye ball movement
electrically. This helps in acurate measurements of
nystagmus in caloric and rotation tests.
Clinical correlation
 Vertigo; This is a disorder of vestibular function.
This occurs in situations when the cortex record a
head movement that has actually not taken place.
Characterized by:-
Hallucination of motion
Dizziness
Nausea
Vomiting
Clinical correlation cont..
 Meniere’s disease, the hair cell of one vestibular organ
is hypofuncting, as a result the other side predominate
in nerve impulses.
 This situation is interpreted as a head movement.
As a result the eyes deviate to retain field of the last
gaze:-
NYSTAGMUS
HALLUCINATION of MOTION occur.
Muscles are adjusted:- STAGERING-DIZZINESS occur.
This illusion of excessive head motion stimulates the
vomiting center in the medulla.
Clinical correlation cont…
 Motion sickness
 The reaction of vestibular system to unaccustomed
stimulation from the motion of an aircraft, ship, or
land vehicle to produce a sense of;
 unsteadiness
 abdominal discomfort
 nausea
 vomiting.
references
 Guyton & Hall
 www.wikipedia.com